Question About OmniPod 5 Cost

Hello folks. I’m a new member here, although I’ve been observing the discussions for a while. I’m a T1, and recently was encouraged to start the OmniPod 5 at Kaiser Senior Advantage (Medicare). I picked up my supplies on Monday, but I was so shocked by the price that I have cancelled my training and decided to not use the OmniPod 5, even though I really wanted to stop giving myself 6 - 8 insulin injections a day. Anyhow - I’m just curious how the price Kaiser gave me compares with what everyone else is paying, because I am retired, and unwilling to spend this much just to avoid injections.
The Starter kit, which includes 11 pods and a PDM, plus some other minor stuff, was $100, which I consider VERY reasonable (I found starter kits online at straight retail for 5 times that). For some reason, my Endocrinologist also included 6 additional pods in my prescription, and Kaiser charged me $300 for them. I asked my Endocrinologist if that was what I could expect to keep paying for the pods, since that coupled with the 4 extra vials of Humalog she also prescribed to keep the pods filled comes to a monthly bill of $650. That means I have a co-pay over $50 every three days. My Endo said she thought that was normal, even though I have since found out that I was her first referral for the OmniPod 5. My question for the OmniPod 5 users here is - is that what you all pay? I found pods for less than that online with no insurance.

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Omnipod Dash (filled the same way as 5 through prescription benefits) costs me $450 every 90 days(45 pods) through the BCBS plan I’m on.

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Hi @bgggale and welcome aboard at FuD. Unfortunately I think there are only a handful of us Omnipod 5 users so far. I will weigh in but maybe others have thoughts too. That price does not sound good to me if it was truly for 6 pods. They come 5 in a box so maybe she ordered 6 boxes = 30 pods which is a standard 3 month supply. If that was the order, $300 for 30 pods is not bad at all. 4 vials of insulin would keep more than 4 pods filled. I usually figure 5 pods per vial.

I started out with a Medicare Advantage (Humana) and my co pay was $218 for 15 pods. Recently I switched to a Part D Prescrip Plan (Cigna) and paid $230 co pay for 15 pods. My monthly order is 15 pods because I asked my endo to prescribe it as 2 days per pod which occasionally happens.

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John58 - unfortunately, what I received from the Kaiser pharmacy was 6 pods, not boxes, for $300! That’s $50 per pod, which means15 pods would cost me $750. I’m starting to think I’m not crazy to think this is just a bit expensive. I asked my Endocrinologist to inquire about the price I paid, but she just said it is what it is. Guess I’ll forget about using the OmniPod 5. Too bad. I was really looking forward to giving it a try. Now I’ve got $400 worth of equipment that is of no use to me.

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Might as well hang onto them…There’s always different insurance options with Medicare Advantage, or maybe Kaiser will decide to cover it with better coverage on their formulary. I had Humana Gold Plus which was an HMO but other than that was good coverage for Omnipod, Dexcom, insulin.

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This question still seems to be up-in-the-air. The recent legislative changes could cause a very, very major change to the cost. The O5 system is basically the O5 pods and the Dexcom G6 CGM, I think you have to pay for your own smartphone (that’s maybe $200 OTC). All of those items seem to be, potentially, Part D, but there is difference of opinion and/or uncertainty about this.

If those items really all are prescription benefits covered under Part D (they should be) then your per month cost next year including insulin is the limit; $166 per month, though in this case you have to pre-pay the whole year in two installments (basically $1000 in January, $1000 in February).

Like I said, no one has really worked this out and, until the squirrelly details in the legislation are published, analyzed and codified no one will know. There are discussions about all this on tudiabetes.org as well.

My personal opinion is that any closed loop system can be a life changer; for me on 2 months using another (not available on Medicare) I’ve been rejected by endos so far twice because, literally, “[They] can’t do anything for me.” The first rejection was when I was just using Omnipod Dash (an open loop system), the second is with my new system and was accompanied by a declaration that the endo had, “Never seen numbers this good in 20 years.” Neither have I, but I have 50 years experience.

It’s worth trying the O5 if you can get it because, while it cannot save your life, it might make it much much more enjoyable and even longer. To me the cost, for my life, ends up being ridiculous but not unaffordable; I’m not yet in Medicare so I pay $7,000 a year (in addition to insurance premiums). Medicare for the first time is starting to sound like a good deal for T1s, rather than a death sentence; $2000/year and lower insurance premiums is a big win :slight_smile:

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So the starter kit with 11 pods is considered a 1 month supply since each pod lasts 3 days unless you use more than 200 units in 3 days. Were you charged the full retail price of a box of pods because that was considered extra for the 30 days and not covered? If you just stuck to the two boxes every 30 days would it make a difference?

BTW If you use a lower amount of insulin and your site is still working well you can totally get 80 hours out of each pod. I routinely get 80 hours unless the site is going bad. That gives me almost a full month of extra pods a year. I dont mind some odd hour (1am) pod changes though.

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I strongly suspect that was the case.
I used to get my insulin from Kaiser by mail (delivery is free) but one time UPS failed to make delivery on a Friday and my insulin sat in a hot warehouse (it was summer) until Monday. I called the pharmacy and told them I wanted a replacement, and they sent one, but charged me $300 for it. The next time I foolishly ordered insulin via mail, UPS lost the package, and apparently told Kaiser, who sent me a second vial I didn’t even ask for and again charged me $300! I now only get my insulin in person at the Kaiser pharmacy.
I asked my Endocrinologist if that might be the case, and she said she didn’t think so. I then asked her to ask at the pharmacy when she was seeing if they would take my OmniPods and Starter Kit back (which I knew they would not) but she did not. It’s funny, because she was the one who INSISTED I need to go on a pump, even though I told her the only one I would consider is the OM5, so I guess she doesn’t want any of her patients to go with the OmniPod 5. Too bad for me and the rest of them.

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Does her office use “Glooko”? Glook supports certain hardware devices, but an office that uses it pretty much needs to have all patients use supported devices.

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I do not know. I only know that she recommended the Dexcom G6 right after it came out, and I’ve been using it ever since, so it makes sense that she also recommends the OM5, since that works with my Dexcom. Does Glooko? I’ve never heard of it. I didn’t want a pump with a tube.

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Omnipod 5 works with Glooko. The controller uploads on its own to Glooko once a day. I think all the info is in the starter kit? You just sign up for a account along with a podder central account before your first training.

Have you tried calling your Omnipod rep about insurance cost? I’m not on medicare but my rep knew exactly how much it would cost me per month. Plus when I was denied he bugged the endos office for the appeal.

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If by Omnipod rep you mean the person who contacted me regarding training and setting up the OM5, she said she has no idea what the pods should cost. She did say $50 per pod sounded outrageous to her, but she refused to check what the price is. I just don’t understand how these folks expect to sell this thing with that attitude.

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My CDE does the training so I’m not familiar with the omnipods trainers and what they do. I have a regional rep that I worked with to help get insurance coverage. On Omnipods website they have a check your insurance coverage option. I signed up and asked to be contacted and that’s how I got assigned a regional rep who told me what my final cost would be and the mail order pharmacy to go with. He was very helpful and after I left a message that I was denied he contacted my endo the same day to get him to file a appeal.

Fifty dollars per pod is the full retail price of each pod without any coverage.

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I.e. what Medicare pays (Medicare, the CMS, not those on Medicare, who, at least next year, should be paying at most $2000 for 121.7 of them; $16/pod, if you don’t use insulin in them and have no other medical expenses…

$50/3 days is $6000/year, which is what I describe as the “idiot max[1]”; the price someone pays who just buys Omnipods (in this case), nothing else. We buy all other kinds of stuff because, firstly, we are not idiots, and secondly we have to.

If we obsess on the price we lose the benefit and that will certainly kill us. Closed loop systems really can make enormous changes to any T1D who is prepared to work with them. Yep, that may mean major changes in diet, but for me the benefit of going from around 7% to, at last count, 5.8% is certainly worth the diet change. O5 is for the people who, quite rightly, don’t want to go it alone and so far it seems to be helping a lot of people. I count the people who are helped; that is the point.

[1] I learned the term on a schoolbus to DisneyWorld in Florida when I was in my '20s. The phrase I was taught was “idiot tax”; the money a corporation would pay for, well, a trip to DisneyWorld because it didn’t do the math.

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Well, I took a closer look at the smallish boxes that the additional pods are in, and I now see they each say ‘5 PACK’. Since I’ve never seen the Omnipod 5 before, I didn’t realize how small the pods are. I’m used to the huge installer for each Dexcom 6 sensor.
That changes things considerably, but I still can’t figure out why my Endo ordered so many, and also why she couldn’t even tell me I got 30 pods for my $300 instead of the 6 for $300 that I contacted her about. I guess I will schedule training now.

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30 pods sounds like a 3 month supply. Good luck with the Omnipod 5!

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Actually, if you include the 11 pods in the Starter Kit, I have a 4 month supply. Odd, since I’m just starting out with it. What if I decide I don’t like it? I get setup and trained next Tuesday. Incidentally - I only noticed the small ‘5 PACK’ label on the side after moving the plastic that was wrapped around the 6 boxes in such a way that I could only read the top and bottom of the boxes.

Don’t you guys and gals have maximum out-of-pocket limits?
Mine is 7,000 per year and while expensive, I reach that by March and from then on everything is completely covered!

Well - I got my Omnipod 5 training this morning, and I’m ‘on the pod’. At the moment, 127 mg/dL and dropping. I just got off my treadmill, so I’ll see if I need to activate ‘Activity’ in the future. I elected not to, since after eating some cashews for lunch, and bolusing for their 24g of carbs, I went up to 180. I know the Omnipod 5 needs approximately 3 pods to ‘learn’ my insulin needs, but so far, I am happy (and not missing giving myself injections).

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